Good Intentions Gone Bad- The Medicare Reimbursement Debate

Author: S. Bledsoe, M.D.

If you’ve been keeping track of the rollout of Obamacare, you know that Oct. 1, 2012 had serious repercussions for many hospitals- about 2,200 hospitals nationwide to be exact.  These hospitals have been identified as having a 30-day readmission rate that is considered too high.  The government’s answer to this problem is penalize these hospitals by decreasing their Medicare reimbursement by 1%.  This will gradually increase to 3% over time.  It is estimated that this will cost the hospitals almost $300 millions over the next year.  This represents around 0.3% of the total amount that Medicare pays hospitals.  This adds up to trouble for the patient.


If I were to grade this idea, I’d give it an “A” for good intentions and an “F” for implementation.  My major problem with this misguided attempt is that all patients are not the same.  The vast majority of patients are engaged in their health care.  They want to get better, and they want to return to their normal lives.  But some people are what we call “non-compliant.”  They will not take care of themselves.  They will not follow the doctors instructions.  They will not follow-up appropriately.  This begs the question, why would a patient not follow their doctors instructions?  Let me give you a few reasons.


Some people purposefully abuse the medical system.  When I was in training, we had a patient “Ms. Smith” who was in our hospital every 3-4 weeks with the same complaint of abdominal pain.  She had the million-dollar work-up, including exploratory surgeries, but she was always back for more.   As my training continued, I began to cover two additional hospitals.  Imagine my surprise when I found that “Ms. Smith” was admitted to one of these hospitals.  A little research uncovered that she basically had a little circuit of hospitals in town that she would go too.  She would get discharged from one, go home for a day or two, get readmitted to a different hospital, and repeat the cycle.  She basically lived at one hospital or another most of the year.


Some people purposefully self-sabatoge.  I’ve had prisoners swallow safety razors 5 or 6 times, so they could get out of prison.  I’ve had people stuff foreign bodies or even stool in their wounds, because they like the attention they were getting when they were sick.  If they left the hospital, they wouldn’t be sick and no more attention.  I’ve had people in the middle of an active stroke walk out of the hospital and not return, because we didn’t want them to go outside and smoke while they were on a medication drip.


Some people, surprisingly enough, just can’t seem to make rational decisions.  Consider that 6% of people think the moon landings are a complete hoax.  7% of people believe that Elvis is still alive.  If you can’t be convinced that Elvis is dead, how can I convince you to take this little pill and see me again in 2 weeks?


Substance abuse will cause people to ignore or not remember their doctors instructions.  7.4% of Americans meet criteria for alcoholism.  Around 1,000,000 Americans are considered “hard-core” heroin users.  Almost 9% of the U.S population currently uses some form of illegal drug.  Over 6 million people abuse prescription medications.  Certainly, these numbers represent a lot of overlap (heroin users are also likely to abuse prescription drugs and alcohol), but suffice it to say, substance abuse is a real problem in America.


Psychiatric disease can also play a role in being “non-compliant.”  Psychiatric diseases can range from mild to disabling.  Schizophrenia is present in around 1% of our total population.  Antisocial personality disorder occurs about 1% of the time.  Major depressive disorder is the leading cause of disability for Americans aged 15-44 and occurs in 6.7% of the population.  The National Institute of Mental Health has a list of the most common mental disorders in the United States.  Mental disease is real, disabling, and problematic for medical care.


Finally, dementia, often undiagnosed, can play a role in a patients ability to follow their doctors instructions.  About 1 person in 7 over the age of 71 has some type of dementia.  It’s scary to learn that ½ to 2/3 of all dementia is currently undiagnosed, including almost 80% of mild dementia flying under the medical radar.  I can tell you that dementia can be very subtle.  I have had many, what I thought were, normal conversations with elderly patients only to find out the next day that they couldn’t remember any of the conversation.  I like giving instructions to both the patient and a family member, no matter what the age of the patient, in order to ensure that there is no confusion.  Regardless, confusion can occur, and dementia can play a role.


I’m guessing here, but I would estimate that 10-20% of all patients nationwide have a medical diagnosis, substance abuse problem, ulterior motive, personality quirk, or decision making capacity that puts them at a high risk for ignoring or not following their doctors direct instructions.  To ignore this and put the responsibility totally on a hospital system is ludicrous.


Just so there is no misunderstanding, treating difficult people is something that every physician, nurse, and hospital is ready and able to do.  We all recognize that we will run into drug addicts, psych patients, dementia, personality disturbances, and, occasionally, homicidal patients.  Everybody deserves a chance at life and improved health, and we work tirelessly to bring improvement to everyone.  This isn’t a complaint that we have to care for them.  This is an expression of concern that reimbursements for hospitals are tied to things well outside of their ability to control.


Why should you care about this?  Who cares if a hospital gets a cut in payment?  In a single word…access.  Hospitals are already financially strapped.  Rural and inner city hospitals are in particularly difficult financial straits.  I know from personal experience that hospitals can go bankrupt.  That situation is bad for the employees and the community that is served.  I fear that diminished payments will result in more hospital closings.  This can result in serious access issues for patients who have to drive longer and longer distances to hospitals that are drowning under the new influx of patients.


I think that while the people who dreamed this up had noble intentions, the cure is worse than the disease.  I can only hope that either I am wrong or this error is corrected before serious damage is done to our hospital systems.

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One Response to Good Intentions Gone Bad- The Medicare Reimbursement Debate

  1. Zina Green says:

    Thought provoking article! Just goes to show that more than the road to hell has been paved with good intentions.

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